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1. Please provide your full name? (Required.)

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2. Please provide the date of service (on what date did the ambulance respond)? (Required.)

Date

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3. Please provide the patients full name? (Required.)

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4. Please provide the names, if possible, of the providers that treated you or your family? (Required.)

Primary Provider Secondary Provider Crew 3 Crew 4 Crew 5
Crew Members

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5. The ambulance responded in a timely manner? (Required.)

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6. The EMS personnel looked and acted professionally, and cared for me professionally and respectfully? (Required.)

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7. The EMS personnel listened and showed concern for my questions and/or worries, and included me in treatment decisions?
 (Required.)

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8. This space is reserved for compliments about the crew members or the service of Gaston County EMS.

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9. This space is reserved for complaints about the crew members or the service of Gaston County EMS.

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10. This area is reserved for suggestions for the services rendered by Gaston County EMS.

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11. Overall how satisfied were you with the services provided by the Gaston County EMS? (Required.)

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12. Would you like to be contacted regarding a compliment, complaint, or suggestion? (Required.)

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13. If you would like to be contacted regarding a compliment, complaint, or suggestion please provide your phone number or email here:

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